Connecticut
Medicaid Managed Care Council
Legislative Office Building Room 3000, Hartford CT 06106
(860) 240-0321 Info Line (860) 240-8329 FAX (860) 240-8307
www.cga.state.ct.us/ph/medicaid
Present: Sen. Toni Harp (Chair), Rep. Vickie Nardello, Rep. David McCluskey, David Parrella & Rose Ciarcia (DSS), Barbara Parks Wolf (OPM), Thomas Deasy (Comptroller’s Office), M.L. Fleissner for Dr. Ardel Wilson (DPH), Ellen Andrews, Dr. Wilfred Reguero, Dr. Edward Kamens, Dr. Alex Geertsma, Janice Perkins (Health Net), Dr. Hank Goldstein, Jeffrey Walter.
Also present: Dr. Mark Schaefer & Hillary Silver (DSS), William Diamond (ACS), Paula Smyth (Anthem BCFP), Sylvia Kelly (CHNCT), Douglas Hayward & James Gaito (Preferred One), Judith Solomon, Deb Poeria (SBHC), Mariette McCourt (Council staff).
Ø
Behavioral
Health, Jeffrey Walter, Chair: Created
a BH Pharmacy Work Group, a collaborative process among psychiatrists, clinics,
MCOs, DSS, and DCF to improve administrative procedures related to patient
access to psychotropic drugs. Expect
to have a report on the BH outpatient outcomes study at the March 16 meeting,
continued updates on BHP and KidCare and clinical applications of a variety of
Intensive Home Based Services.
Ø
Consumer
Access, Irene Liu & Christine Bianchi, Co-Chairs: addressed several key health care coverage access items with
DSS follow up: 1) HUSKY member address changes – the DSS is working with
central office and Regional staff to approve procedures for the acceptance of
address changes and allow MCOs to submit an electronic file to DSS with updated
changes, 2) HUSKY A eligibility differences between the AEVS system and MCO
records – providers should check with the patient’s MCO plan for member
status, as this is updated daily; HUSKY B eligibility status is not part of the
AEVS system, therefore providers should contact ACS, give their Medicaid
provider ID in order to receive patient HUSKY B eligibility verification, 3)
delays and confusion about the DSS policy for expedited eligibility for pregnant
women is being addressed through regional training programs for community-based
organizations and regional DSS staff.
Ø
Quality
Assurance, Paula Armbruster, Chair: The HUSKY Obesity Work Group has developed a
provider information matrix regarding obesity-related services and will consider
further recommendations to the full Council.
The Subcommittee is 1) developing revisions to adolescent anticipatory
guidance items for the State EPSDT periodicity table form, 2) will identify
focus issues at the 2/26 meeting.
The
DSS was asked to discuss the current status of the various State Plan Amendments
(SPA) originating from the 2003 legislative session (see attachment of the
overhead presentation):
·
Public Hospital disproportionate share (DSH)
was submitted to allow CT to claim a federal match (FFP) of 175% for costs
incurred in service delivery in CT’s only public hospital, John Dempsey.
Congress has extended the window for this FFP rate for public acute care
hospitals for FFY04-05. The Centers
for Medicare & Medicaid Services (CMS) continues to question the State about
the appropriateness of replacing state funds for JD hospital operating expenses
with Medicaid, which allows the federal match.
·
The State has received approval from CMS for a
federal match for services delivered in the State general assistance (SAGA)
outpatient, medical and GABHP. Prior
to this, CT only claimed acute inpatient SAGA stays under Medicaid, using the
DSH program as the vehicle.
·
Urban DSH expansions for several acute care
hospitals has been approved by CMS, with the effective date 10/1/03. Council
members noted it will be important to distinguish what the hospitals receive
compared to the State.
·
Non-emergency medical transportation
SPA makes a technical change in CT regulation language in order to be compatible
with federal regulations. Transportation for ‘medically necessary covered
services” was replaced with “Medicaid covered services”.
·
Rehab option SPA was sent to CMS 12/03.
There have been ongoing discussions with CMS on the list of services, the
rate methodology, distinction of IMD vs. non-IMD facilities.
o
An IMD facility, defined as less than 16 beds whose
sole services are mental health services for recipients aged 21-65 years, is
ineligible for Medicaid match.
o
Targeted Case Management (TCM) needs to be defined
separately, according to CMS, in the rehab option so as not to claim federal
match twice for the same service. The
TCM traditionally allow broader case management beyond linkage to Medicaid, as
determined by agencies that may apply TCM to specified populations.
For example DMHAS released a policy transmittal in the 2003 summer that
identifies diagnostic codes that would be under the agency’s TCM.
o
While the Governor’s FY05 budget focused on CT
rehab options for mental health and substance abuse residential services, the
Mercer (CT actuarial consultant) report identifies a range of services that
might be included in the Behavioral Health Partnership among DSS, DCF &
DMHAS. The state statute is rather
broad in this regard.
·
The SPA for HUSKY B will be submitted to CMS the
last week of February. When asked
what would happen if 2004 legislation rescinds the HUSKY B changes, the DSS
stated that if CMS had approved the SPA based on 2003 legislation, the SPA would
have to be changed if subsequent legislation is enacted.
If the SPA is still under review with CMS, the State can rescind the
amendment. The DSS reviewed the HUSKY
B changes in the SPA:
o
New premiums in Band 1, (family income
>185%-235% FPL): $30/child/month and $50/month for families with 2 or more
children enrolled in HUSKY B.
o
Increased premiums for band 2, (families with
income 235-300%FPL): increased to $50/child/month and $75/month for 2 or more
children enrolled in HUSKY B.
o
The combined amount of premium & co-pays cannot
exceed 5% of family income. The
maximum family cost share is now $760/year.
Senator
Harp and other Council members requested the DSS provide the amount of state
savings associated with each of these SPA that was allocated to the General
Fund.
·
The DSS has had to focus attention
on the SPA and major potential policy changes such as the BHP, and less on the
HIFA 1115 waiver.
·
HUSKY adults(16,000) under the 2nd
Appeals Court of New York restraining order (TRO) remain insured in HUSKY A.
They will remain covered until the court issues a decision.
·
The DSS was asked if CT was considering
implementing the ‘Kentucky Plan’ in relation to Medicaid co-pays, in which
providers other than FQHCs, hospitals or nursing homes, are informed by the
State that they may refuse future services to Medicaid clients that have unpaid
fees such as co-pays. The DSS
stated such a plan has been developed but is on hold at this time.
·
The DSS internal/external review team has scored
dental ASO bidder responses. The
selection recommendation will be made to the Commissioner and then be announced
publicly.
The CMS had planned to
require states (notice in Federal Register 1/7/04) to submit their proposed
budgets to CMS 5 months prior to the new SFY (by February in CT) so the federal
government could identify the source of federal match dollars and evidence of
state programs associated with federal match dollars. This proposal is related in part to states, with county
health delivery services that set a high rate for the county services that are
transferred back to the state (intergovernmental transfer-IGT) and for which
some states have received high FFP rates. Connecticut
would probably continue to receive the same federal revenue, as there is little
IGT, but would have more reporting requirements as well as CMS questions to the
legislature regarding the budget process. Subsequent
to bipartisan comments, the CMS has agreed to reissue the same or revised
proposal and allow a 60-day comment period.
Comments:
·
The DSS noted that historically,
the Medicaid budget has not been fully funded, with budget adjustments made for
DSS deficiencies mid-year. Under the CMS proposal, the State may be required to explain
the Medicaid deficits and need for additional state funds before the federal
match would be approved.
·
Sen. Harp noted that this may
require the State to assess the constitutional spending cap since the state
consistently under-budgets Medicaid.
HUSKY A Dental/Behavioral Health
Revenue/Expenditure Reports
The
DSS had stated they could comply with the request to present data on
administrative & medical revenue and expenditures and profit margin for
dental and BH services; however individual plan information could not be
released until the dental/BH ASO selection process was complete.
Legislation requires the DSS to report on managed care plans’ at
–risk subcontractor revenues and expenses quarterly to the Medicaid Council.
The Council found the information reported at this meeting incomplete,
absent aggregate administrative/medical and profit margin information. Further, while skeptical about the reports’ adverse impact
on the ASO process since the carve-out includes populations other than HUSKY;
the council members requested plan specific data be reported as soon as
possible. It is important that the
public have information on each MCOs use of state/federal dollars in service
delivery for dental and behavioral health care.
Total
Paid and Per Member Month, HUSKY A
|
|
2002 |
1st
half 2003 |
Behavioral health
|
|
|
|
Member
months |
3,441,027 |
1,801,882 |
|
Net
BH Expenditures |
$49,463,122 |
$29,004,203 |
|
Reinsurance payments |
$23,107,956(represents 46% of
total BH expenditures) |
$12,249,921(represents 42% of
total BH expenditures) |
|
$
PMPM |
$14.37 |
$16.10 |
Dental
|
|
|
|
Member
months |
3,441,027 |
1,801,882 |
|
Dental
care Expenditures |
$26,282,728 |
$14,464,683 |
|
$
PMPM |
$7.64 |
$8.03 |
·
The BH reinsurance dollars represent 42-47% of the
total dollars spent in BH services; the State pays the MCOs reinsurance dollars
for inpatient stays beyond medical necessity.
·
Senator Harp stated that lack of available
community resources contributes to these high reinsurance costs.
The Senator believes that leadership outside the state agencies is needed
to put resources into the community level care system; the development of step
down levels of care in the Behavioral Health Partnership plan is not clear.
The Senator stated it would seem, based on meetings with some providers,
that DCF has failed to reach out to those providers that have indicated
available resources for step-down beds.
·
Dr. Schaefer (DSS) stated that there is every
expectation of future improvement in the BH delivery care model when incentives
for long inpatient stays are removed, DCF will be better able to manage the
length of stay in residential facilities and that conversion from a grant system
to a FFS system allows flexibility for the growth of the community system.
·
Preferred One reported a 24% reduction in the
plan’s State reinsurance dollars over a year as the BH subcontractor worked
with providers to develop community–based care.
·
Based on the 1st half 03, dental/BH PMPM
dollars and the statewide aggregate FY03 MCO PMPM rates:
o
2003 Dental PMPM dollars represent 4.7% of total
PMPM rates, while BH represents 9.4%.
o
The dental PMPM dollars increased by 4.7% ($.39)
from 2002 to 2003, while the BH PMPM dollars increased by 11% ($1.73) in 2003.
The
Council requested the MCOs come to the March meeting prepared to discuss how the
health provider rates have been impacted by the MCO rate increases.
The
Department was asked to present EPSDT service utilization trends by age over the
life of the managed care program. The
HICFA 416 reports are the source of the data presented. Of note, FFY 1995-96
data represents non-managed care data and from 1999 forward adolescents are
required to receive yearly EPSDT services, which changes the denominator
(required EPSDT visits) and may result in lower ratios.
Screening ratio is that percent of recommended well child screens
received, participation ratio is the percent of children/youth receiving
well child screens. EPSDT
discussion:
·
EPSDT screening ratio for all HUSKY A children has
increased and remained at about 70% from 2000-02. FFS ratio was about 50% in
1995-96.
·
EPSDT participation ratio for all HUSKY A children
has increased and remained constant from the FFS 42% level to about 55% from
2000-02.
·
There was a decrease in both ratios in 1999,
influenced by the 20% drop in adolescent ratios.
·
The reduction in both the <1 age group ratios in
2001 is unexplained. Overall screening and participation ratios have increased
since 1999 by 20-30 % points for the <1 and 1-5 age groups compared to lower
FFS ratios of 40-50%.
·
The 6-14 age group has increased to a plateau of a
55% screening ratio, and 50% participation ratio since 2000 (FFS screen rates
were about 45%).
·
The 15-20 age group, while improved from the FFS
period (<20%) to 50% screen ratio, the participation ration remains flat at
32% (25% in 95-96) since 2000.
·
Sen. Harp asked the MCOs if they are targeting the
15-20 age group to improve preventive care visit utilization:
o
CHNCT stated they have developed a Youth Council to
determine what would engage youth in preventive care and plan to test incentives
to see if there is an accompanying improvement in utilization.
o
The DSS has added contract language for MCOs to
develop outreach to this age group to improve utilization of preventive care.
Sen.
Harp requested the four MCOs discuss their plans to target adolescent preventive
care at the April Council meeting. The
Senator also asked if there could be an assessment of what the preventive visit
includes, since the relevance of preventive care and adolescent engagement may
be influenced by the content of the visit.
Sen. Harp also noted that mandatory school exams increase the EPSDT
rates. The Senator suggested that
if professional organizations believe more frequent preventive visits are
appropriate, they may influence state-level health policy regarding this.
Discussion
of dental utilization:
·
The pattern of higher preventive dental service
utilization under FFS compared to HUSKY A is evident among all age groups.
The percentage of children who have received preventive dental
services is actually slightly less than FSS rates in 1995-96: 32-38% FFS
compared to 32-35% since 1998. HUSKY A preventive care includes cleanings, fluoride,
sealants, but not exams.
·
Preventive dental care for the 1-5 age group also
is over 10 % points lower since 95-96 FFS:
25-30% FFS compared to 17-20% since 1999. The reduction is also seen in
the 6-14 and 15-20 age groups.
·
The percentage of children receiving any dental
service from FFY 1999- 02 has shown a fairly flat rate of 35-38% in the age
3-5 group, a higher but constant rate of 45-50 % in the 6-9 and 10-14 age group
and some increase in services (about a 5% increase) for the 15-20 year age
group.
·
The exclusion of oral exams from the preventive
dental care data may result in under- counting preventive services.
The DSS was asked to do a test run on exam/cleaning data to identify
differences.
·
The DSS was asked to use the data to identify where
the services were performed. This information could better inform budget
decisions about allocations.
William
Diamond reviewed the ACS call volume and enrollment changes effective January
2004:
·
Call volume to the HUSKY call center increased by
2622 calls, many of which were related to the HUSKY B premium change notices.
There were similar increases last year when notices were sent out
regarding HUSKY changes such as continuous eligibility.
·
Overall HUSKY A enrollment increased by 1335
members.
o
Adults (including parents/caregivers at or
<100%FPL) increased by 407 members.
o
Under 19 enrollment increased by 928 members.
o
HUSKY B children’s enrollment decreased by 472.
Council
discussion related to HUSKY A & B eligibility:
·
At the Council request the DSS will:
o
Provide the council with RWJ Retention reports that
track ‘churning’ in the HUSKY program with a one month look back at the
status of those who had lost eligibility in the previous month
o
Work with ACS to identify the percentage of
adults(4079) & children (7536) that lost eligibility in June/July 2003 that
have come back on the system.
·
The impact of the HUSKY B premium changes will be
evident in the March enrollment data. Anthem
BCFP commented that they have added 4 staff to deal with the HUSKY enrollment
changes. Additional MCO staff
increases administrative expenditures that, when included with DSS/ACS
administrative costs, may well offset some of the savings projected with the
cost sharing increases.
·
Health insurance loss/gaps secondary to the HUSKY B
changes and HUSKY A elimination of continuous eligibility, presumptive
eligibility have begun to alter the care delivery system with possible increased
demand on the ‘safety net’ system.
o
Sen. Harp requested the DPH to report on the SBHCs
experience with trends in the uninsured.
o
The CT Hospital Association will be asked to
provide information on changes in the insured/uninsured in Emergency Departments
and hospital clinics.
·
According to one practitioner, the hospital clinic
practice enrollment sheets are identifying more uninsured children, who may be
referred to the FQHC for general services.
The hospital, which provides specialty services, requires payment
‘up-front’ by the uninsured family. There
was a discussion about hospital DSH payments and if hospitals can include
outpatient uncompensated care along with inpatient care in the DSH claims.
While the federal government allows outpatient and inpatient care in
determining hospital DSH amounts, CT statutes determine hospital’s obligations
related to the acceptance of DSH dollars and the provision of uncompensated care
(there does not appear to be such statutory obligation).
The amount budgeted for hospital DSH payments also influence the
distribution of DSH for inpatient versus outpatient services.
The
Medicaid Council will meet Friday March 12, 9:30 AM in LOB RM 2D.
